Treatment of depression at antiretroviral initiation could have a considerable impact on mortality

Depression at antiretroviral therapy initiation and clinical outcomes among a cohort of Tanzanian women living with HIV.

Sudfeld CR, Kaaya S, Gunaratna NS, Mugusi F, Fawzi WW, Aboud S, Smith Fawzi. AIDS. 2017 Jan 14;31(2):263-271. doi: 10.1097/QAD.0000000000001323.

Objective: The objective of the study was to assess the relationship of depression at antiretroviral therapy (ART) initiation with mortality and clinical outcomes among Tanzanian women living with HIV.

Design: We conducted a prospective cohort study of 1487 women who initiated ART in Dar es Salaam, Tanzania.

Methods: Symptoms of depression and anxiety were assessed using a Tanzanian-adapted and validated version of the Hopkins Symptom Checklist. Participants attended monthly clinic visits during the first 2 years of ART and CD4 T-cell counts were assessed every 4 months. Proportional hazard models were used to assess the relationship of depression with mortality and clinical outcomes.

Results: Symptoms consistent with depression were prevalent among 57.8% of women at ART initiation. After multivariate adjustment, including social support and stigma, depression at ART initiation was associated with increased risk of mortality [hazard ratio (HR): 1.92; 95% confidence interval (CI): 1.15-3.20; P = 0.01] and incidence of severe anemia (hemoglobin <8.5 g/dl; HR: 1.59; 95% CI: 1.07-2.37; P = 0.02). Under the assumption of causality, we estimate 36.1% (95% CI: 13.6-55.1%) of deaths among the study cohort were attributable to depression and its consequences. Depression was not significantly associated with trajectory of CD4 T-cell reconstitution or the risk of immunologic failure (P values >0.05).

Conclusion: Elimination of depression may reduce mortality during the first 2 years of ART by one-third in our study cohort. Randomized trials and rigorous implementation studies are needed to evaluate the individual and population-level effects of integrated mental health interventions and HIV treatment approaches in resource-limited settings.

Abstract access   [1]

Editor’s notes: People living with HIV are more than twice as likely to have depression than the general population, in both high- and low-income settings. Many studies in high-income countries have illustrated that depression is associated with poor HIV-associated outcomes. There have been relatively few longitudinal studies on this from low-income settings. This study, among women in Tanzania living with HIV, found that over half had symptoms consistent with depression at ART initiation, and this was associated with a two-fold risk of mortality. The results suggest that effective programmes which address depression, such as problem-solving therapy or cognitive behaviour therapy, at ART initiation, could have a considerable impact on mortality. There is a need to evaluate appropriate mental health programmes integrated with HIV strategies in resource-limited settings that address the specific needs of different populations of people living with HIV, such as children and adolescents   

Africa [6]
United Republic of Tanzania [7]
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